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This paper synthesises critique from Māori patients with Bipolar Disorder (BD) and their whānau to identify barriers and propose changes to improve the structure and function of the New Zealand mental health system. A qualitative Kaupapa Māori Research methodology was used. Twenty-four semi-structured interviews were completed with Māori patients with BD and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data. Three key themes identified the impact of structural features of the New Zealand mental health system on health equity for Māori with BD. Themes involved the accessibility, delivery and scope of the current health system, and described how structural features influenced the quality, utility and availability of BD services for Māori patients and whānau. Structural barriers in the existing design, and potential changes to improve the accessibility, delivery and scope of BD services for Māori, were proposed including a redesign of operational, environmental, staffing, and navigation points (information, transition, fatigue) to better meet the needs of Māori with BD. A commitment to equity when implementing structural change is needed, including ongoing evaluation and refinement. This paper provides specific recommendations that should be considered in health service redesign to ensure the New Zealand mental health system meets the needs of Māori patients with BD and their whānau. [ABSTRACT FROM AUTHOR]

Objectives:The current study aimed to explore if the impact of various risk factors for chronic disease differed for people of Chinese, Indian and New Zealand European and Other (NZEO) ethnicities. Design:Data analysed for this paper was extracted from the 2003–04 and the 2006–07 NZ Health surveys for adults aged 25–70 which used a cross-sectional survey design. Data from both the survey waves were combined and all statistical analysis was done using SAS version 9.2 or 9.3. Ethnicity of participants was coded using a priority-based classification system as (1) Indian, (2) Chinese, (3) Other Asian, (4) NZEO, (5) Maori and (6) Pacific. Only data for Indians, Chinese and NZEO were used for the current study. Prevalence estimates and 95% confidence intervals for chronic disease and the associated risk factors were generated to describe the sample. Logistic regression analysis was used to examine whether the difference in the change in risk of chronic disease with different exposures was different according to ethnicity. Results:Higher deprivation resulted in increased risk of chronic disease in Indian and Chinese males but not in NZEO males (p= .03). There was a weak evidence for a differing effect of physical activity (p = .10) on chronic disease with the protective effect not seen in Indian or Chinese participants. Conclusion:The results of the current study indicate that some factors such as socio-economic deprivation and physical activity may impact differently on the prevalence of chronic disease according to ethnicity. The authors recommend further investigation of these factors using improved and innovative methodology and high-quality ethnicity data to better understand the factors underpinning ethnic disparities in disease prevalence among Asian sub-groups. [ABSTRACT FROM PUBLISHER]

Objective. This study examines the development of new tools for analysing links between ethnicity and health outcomes. In a New Zealand context, it focuses on (1) how ethnicity is increasingly articulated as a social construct, (2) how individuals belonging to more than one ethnic group have been recorded and reported in research, and (3) health research and policy implications of the growing proportion of New Zealanders who claim multi-ethnic affiliations. Design. New Zealand provides a microcosm in which to consider ethnicity, indigeneity, migration and intermarriage, and their interacting effects on society, culture, identity and health outcomes. Against a backdrop of historical debates about the measurement of race, and then ethnicity, the paper explores recent changes in the recording and reporting of ethnicity in the five-yearly Census of Population and Dwellings, and in death registrations. These changes are then considered in relation to the study of ethnic health disparities and the development of policies to overcome them. Results. In the 2001 Census, of those who responded to the ethnicity question, at a level 1 classification 7.9% gave more than one response. In relation to the indigenous people of New Zealand, of all those who recorded Māori as one or more of their ethnic groups, only 56% recorded Māori only. In the younger age groups, less than half the Māori ethnic group were Māori only. Single ethnic categories disguise considerable within-group diversity in outcomes. Conclusion. While single ethnic group disparity studies have been useful in the past, we suggest that more sophisticated ways of conceptualising and analysing ethnicity data in relation to health disparities are now required in New Zealand. Based on the New Zealand experience, we also suggest that as international migration continues, and as intermarriage becomes more frequent in most countries, there will be pressure to move from single group race-based measures towards culturally-based complex ethnicity measures. [ABSTRACT FROM AUTHOR]

Objectives.New Zealand has a unique tool, Te Tiriti o Waitangi, the Treaty of Waitangi, for addressing health disparities. Indigenous Māori have compromised health status compared to other groups. This paper investigates ways in which public health units (PHUs) and non-governmental organisations (NGOs) use Te Tiriti o Waitangi in service delivery to Māori. Design.A nationwide telephone survey of primary health providers (n=162) was conducted in 2014-15. Participants were asked about effectiveness and monitoring of their service delivery to Māori. Results.PHUs reported actively working with Māori, and Te Tiriti o Waitangi to reduce health disparities. Direct Māori engagement with development and delivery of programmes was viewed as essential. Strategies included designated PHU staff in positions of responsibility, formal partnerships with Māori, and providing operational and strategic guidance. Some PHUs supported development of cultural competencies. NGO responsiveness to Māori was variable. Some NGOs described prioritising service delivery and programmes for Māori. Others reported the focus of their service was European or other non-Māori ethnicities. Lack of resources or past difficulties engaging with Māori were barriers. Conclusion.Public health has an ethical commitment to reduce health disparities. Advancing Te Tiriti obligations in everyday practice has the potential to address inequalities. [ABSTRACT FROM AUTHOR]

Action Research can be a powerful tool for change and improvement in health services for indigenous people when utilised within an appropriate framework. The project Maori Utilisation & Experience of Ischaemic Heart Disease Management illustrates this convergence in its use of Kaupapa Maori Action Research methods in its efforts to improve the health and well-being of Maori within the northern region of Aotearoa/New Zealand. We outline the research processes and outcomes obtained through the application of 'by Maori for Maori' approaches to understanding Maori pathways and barriers to care for ischaemic heart disease. Maori understandings of their illness and experiences of treatment, and healthcare providers' perspectives on care of Maori with ischaemic heart disease, were combined into Maori-led actions to improve service provision. The paper examines critical factors in an action research approach to health service innovations and implications for efforts to reduce entrenched health disparities. [ABSTRACT FROM AUTHOR]

Objective: To understand what motivates sedentary indigenous and ethnic minority men to become more physically active. Design: We use thematic analysis to present data from a qualitative study exploring 23 sedentary indigenous Māori (New Zealand) men's experiences of completing a 12-week exercise intervention to improve their metabolic health. Results: Four themes emerged: The Bros – having fellowship and mutual motivation; Being better informed about exercise; Impacting overall wellbeing; and Disseminating the findings beyond the study Exercise interventions informed by indigenous Māori cultural values and knowledge increased its relevance to their daily lives. The motivation for these indigenous men was more culturally-based external factors than an inherent desire to lose weight. Conclusion: Indigenous and minority men in many developed countries have high morbidity and premature mortality related to sedentary lifestyles. The low uptake of physical activities possibly relates to focusing more on outcomes such as weight loss which lacks cultural relevance. When offering health promotion interventions for marginalized populations these findings highlight the importance of culturally tailoring interventions to the unique sources of motivation for each group to increase activity to improve their efficacy. [ABSTRACT FROM AUTHOR]

Objective: The aim was to investigate the prevalence of self-reported sleep complaints in New Zealand adults and determine the independent association of sleep complaints with adverse health outcomes. Design: We used 2002/03 New Zealand Health Survey data (n = 12,500 adults, ≥15 years). The prevalence of self-reported sleep complaints was estimated by ethnicity. The relationship between sleep complaints and mental health, physical health and health risk behaviors were investigated using multivariable logistic regression models. Results: The prevalence of each sleep complaint measure was highest for the indigenous Māori population (23.6% reported ‘any’ sleep complaint; 10.3% reported multiple sleep complaints). Reporting ‘any’ sleep complaint was associated with higher odds of poorer mental health, diagnosed high blood pressure, diagnosed diabetes, diagnosed heart disease, poor/fair self-rated health, obesity, current smoking, and hazardous drinking. Conclusion: The higher prevalence of sleep complaints among Māori and the consistent association with poor health suggests a potential role for suboptimal sleep in ethnic health inequities. [ABSTRACT FROM AUTHOR]

Objectives: Māori, the indigenous peoples of Aotearoa (New Zealand), continue to exhibit the highest rate of smoking of any ethnic group in the nation. Clarifying the present day factors which perpetuate Māori smoking has become matter of some urgency.Design: We investigate links between subjective elements of Māori identity, demographic factors and perceived discrimination with smoking status in a national probability sample of self-identified Māori (N = 667).Results: Our results suggest that core aspects of Māori identity and cultural engagement were not significantly linked with smoking. However, the extent to which participants felt they were perceived as prototypically Māori (measured as Perceived Appearance) was reliably associated with smoking. The effect of Perceived Appearance held when adjusting for perceived experiences of discrimination and other standard demographic indicators.Conclusion: Our analysis indicates that simply feeling that one is more visibly Māori is associated with an increased likelihood of smoking. This may reflect how Māori negotiate the larger systemic forces of racism present in New Zealand society. [ABSTRACT FROM AUTHOR]

Objectives. To document and explore the experience of migrant care workers providing health and social care to the elderly in institutional care settings and in the homes of the elderly in the community in New Zealand with a particular focus on the affective components of care work. Design. This qualitative study involved conducting face-to-face, open-ended, semi-structured interviews with 29 migrant care workers in the eldercare sector in the cities of Auckland and Wellington, New Zealand. Participants were recruited through various agencies focusing on aged care and engaged with migrant eldercare workers and snowballing through participant referral. Sample size was determined when saturation was reached. The interviews were audio recorded, transcribed verbatim, themes were identified and then analysed drawing on a body of theoretical work in the fields of emotional anthropology and moral geography and the international empirical literature addressing migrant eldercare workers. Results. As with the international research in this field we found that these workers were vulnerable to exploitation, the workforce is largely feminised and stereotypical understandings of racial groups and national characteristics informed recruitment and the workplace experience. Here attributing gradients of affect to particular migrant groups in the workforce was the main mechanism employed to establish worker worth and difference. Identifying with these gradients of affect enabled these eldercare workers to demonstrate that they met the moral and ethical requirements of permanent residency and ultimately citizenship. Eldercare workers in the home were vulnerable to ‘blurred emotional boundaries’ and care recipient demand for greater emotional commitment. The migrant eldercare workers in this study all shared vulnerable residential status and many feared they would never obtain permanent residency or citizenship. All had family who remained in the Philippines and towards whom they had an obligation to substitute care support. Conclusion. Central to understanding how this labour force issue is experienced by both caregivers and the elderly is the notion ofsubjective proximityand how emotional and moral trajectories serve to mediate the connection between the eldercare worker and workplace, the Filipino migrant eldercare relationship with employers, agencies and institutions; and, the transnational nature of this mobility and social and actual citizenship. [ABSTRACT FROM AUTHOR]

Aim.To investigate the influence of ethnicity on immediate and long-term (five years post-partum) foetal, maternal and injury-related outcomes. Methods.A retrospective, population-based study analysing maternal discharge records linked to birth/death certificates for women aged 25 years and under. Discharge records were grouped according to ethnicity (Maori and non-Maori) and as follows: (1) a pregnancy-related hospital admission, but no associated or subsequent assault recorded (pregnant only); (2) an assault-related hospital admission event after the pregnancy, but within five years of the index pregnancy (assault after pregnancy); and (3) an assault recorded within the same hospital admission event as the pregnancy (assault during pregnancy). Generalised linear models for the binomial family were conducted to explore increased risk ratios of pregnancy-related and subsequent injury outcomes depending on ethnicity and group assignment. Results.Compared with the pregnancy-only group, rate ratios (RRs) for maternal and foetal outcomes were higher in the assault after pregnancy group and the assault during pregnancy group. For injury outcomes in the five years after the injury event, RRs for the assault after pregnancy group exceeded both the pregnancy-only and the assault during pregnancy groups. RRs for non-Maori women assaulted after pregnancy were higher for injury hospitalisations, fracture and intracranial injury than those for Maori women. Conclusion.Given that Maori women experience a higher prevalence of severe intimate partner violence and more difficulties accessing health care, we suggest that the findings highlight potential problems for health care access for Maori women experiencing violence. [ABSTRACT FROM AUTHOR]

Objectives.To identify differences in delay for surgical treatment of breast cancer between ethnic groups and to evaluate the role of health system, sociodemographic and tumour factors in ethnic inequities in breast cancer treatment. Methods.A retrospective analysis of prospectively collected data from the Waikato Breast Cancer Register for cancers diagnosed in the Waikato region in New Zealand (NZ) from 1 January 2005 to 31 December 2010. Results.Approximately 95% (1449 out of 1514) of women with breast cancer diagnosed in the Waikato over the study period were included. Of women undergoing primary surgery (n= 1264), 59.6% and 98.2% underwent surgery within 31 and 90 days of diagnosis, respectively. Compared with NZ European women (mean 30.4 days), significantly longer delays for surgical treatment were observed among Māori (mean = 37.1 days,p= 0.005) and Pacific women (mean = 42.8 days,p= 0.005). Māori women were more likely to experience delays longer than 31 (p= 0.048) and 90 days (p= 0.286) compared with NZ European women. Factors predicting delays longer than 31 and 90 days in the multivariable model included public sector treatment (OR 5.93, 8.14), DCIS (OR 1.53, 3.17), mastectomy (OR 1.75, 6.60), higher co-morbidity score (OR 2.02, 1.02) and earlier year of diagnosis (OR 1.21, 1.03). Inequities in delay between Māori and NZ European women were greatest for women under 50 years and those older than 70 years. Conclusion.This study shows that significant inequities in timely access to surgical treatment for breast cancer exist in NZ, with Māori and Pacific women having to wait longer to access treatment than NZ European women. Overall, a high proportion of women did not receive surgical treatment for breast cancer within the guideline limit of 31 days. Urgent steps are needed to reduce ethnic inequities in timely access to breast cancer treatment, and to shorten treatment delays in the public sector for all women. [ABSTRACT FROM PUBLISHER]

Introduction:Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Māori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested. Objective:To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Māori community. Approach:Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design. Discussion:Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages. Conclusion:Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential. [ABSTRACT FROM PUBLISHER]

Objective. To identify and discourse on the complexities of ethnicity and culture, their role in the social and psychological functioning of patients and their potential impact on clinical assessment and treatment of these patients in diverse cultural contexts. Design. Description of aspects of the cultural competence required by clinicians in mental health service provisions in therapeutic interactions involving the therapist and patient and also in the encounter between practitioners. Results. The four-decade clinical experience of the author, an African Jamaican psychiatrist, encompasses clinical experience in the Caribbean, North America, Europe and New Zealand. From this wealth of multicultural clinical practice the author uses personal examples of four experiences with patients and professionals of African Caribbean, British and Maori ethnicities to discuss issues of ethnicity, ethnic identity and stereotyping, culture, cultural competency and alterity in the exchanges between the therapist and patient, and between therapists and the difficulties encountered in effective assessment and treatment of patients in multicultural settings. The author highlights the importance of historical experience in the psychological constitution of patients, which is the basis of a novel analytic model called psychohistoriography. This insight-oriented individual or group-focused intervention was created with the intention of attempting to heal the wounds of history; an aim that is absent from existing psychoanalytic treatment modalities. Conclusion. Psychohistoriography may be a viable therapeutic option in the negotiation of cross-cultural clinical interactions. [ABSTRACT FROM PUBLISHER]

Objective. Using New Zealand as a case study, to determine whether ethnicity is appropriate for communicating sun exposure health promotion messages. Design. This study reviews recent literature on minimising skin cancer risk and achieving sufficient serum vitamin D levels. It draws on a variety of scientific literature, reports and media statements to determine appropriate sun exposure messages for minimising skin cancer risk and achieving sufficient vitamin D status among the New Zealand population, which is diverse with regards to both ethnicity and skin colour. Result(s). Due to a unique combination of factors, New Zealand and Australia lead the world in melanoma incidence. Devising ways of minimising skin cancer risk and achieving optimal vitamin D blood levels among the New Zealand population provide major challenges for researchers and health promoters. These challenges include the many unknowns and uncertainties about vitamin D, such as determining what constitutes an optimal level as well as its association with specific diseases. There is strong evidence that skin cancer, including melanoma, is caused by excess harmful sun exposure with skin colour having long been established as a risk factor. More recently, there has been significant focus in New Zealand on the potential beneficial aspects of sun exposure, mainly in assisting vitamin D synthesis, especially for Maori and Pacific people. But research also shows that Maori and Pacific people are increasingly at risk of developing melanoma. In New Zealand, where there is a high rate of ethnic intermarriage and ethnicity is culturally constructed, there is likely to have been a weakening of the relationship between ethnicity and skin colour. Skin colour information is required to understand both the risks and benefits of sun exposure. In the immediate future, ethnicity appears likely to remain an important reference point for assessing the risks and benefits of sun exposure in New Zealand. However, we contend that while ethnic-based channels may be useful for communicating appropriate sun exposure messages, there are dangers in such advice based on membership of particular ethnic group(s). Rather skin colour, along with other key variables, such as season and time of day, should be the core considerations for assessing and discussing risk. In the longer term, direct measures of skin type are needed when assessing the risks and benefits of sun exposure, including the potential protective effects against various illnesses. Conclusion. While ethnic-based dissemination channels may be useful for communicating about the risks and benefits of sun exposure in New Zealand, discussion of risk factors should focus on skin colour. [ABSTRACT FROM AUTHOR]

Objective. To examine all-cause mortality differentials among New Zealand's (NZ) immigrant population. Unlike other studies that use the total non-migrant population as the reference group, we use NZ-born populations of the same ethnic group for comparison purposes. Our study intends to answer two questions: first, do immigrants have a mortality advantage relative to their NZ-born counterparts of the same ethnicity? Second, does an immigrant mortality advantage, if one exists, decline as duration of residence increases? Design. Data from the New Zealand Census-Mortality Study from 1996-1999 and 2001-2004 were used. The main variable of interest, years of residence in NZ, was classified as living in NZ for less than 5, 5-9, 10-19, 20-34, 35 or more years, and born in NZ. Three main ethnic groups were examined, such as Asian, Pacific, and European/Other. Mortality rates for subgroups within these broad ethnic groups were not calculated. Negative binomial models controlled for socioeconomic and demographic factors to assess the independent effect of duration of residence on mortality. Results. European/Other and Asian immigrants have a mortality advantage relative to their NZ-born counterparts, which declines as length of residence increases. Within strata of duration of residence, there are few differences between European/Other and Asian mortality. Pacific immigrants showed no statistically significant mortality advantage relative to the NZ-born Pacific people, and had higher mortality rates than Europeans/Others or Asians regardless of duration in NZ. Conclusion. Findings from our study are consistent with international literature. Both the healthy migrant effect and acculturation may be responsible for the protective mortality effect among Asians and Europeans/Others that erodes over time. However, our results for the Pacific population suggest some migrant groups come to the host country with a health disadvantage and with no apparent healthy migrant effect. [ABSTRACT FROM AUTHOR]

Introduction. Although opportunities exist for positive experiences in research, Maori in New Zealand, like other indigenous people colonised by Europeans in the nineteenth century, have also been subject to research and associated policies that have had long-lasting negative consequences. Researchers have subsequently been challenged by Maori to conduct research that is acceptable, accountable and relevant. Much of this debate has taken place within the framework of the Treaty of Waitangi, a treaty of cession signed between Maori and British Crown representatives in 1840. Nowadays, health and health research statutes exist that require researchers to respond to the 'principles' of the Treaty. Few practical examples of how health researchers have undertaken this have been published. Aims. We examine how, in developing a national study of injury outcomes, we responded to the Treaty. Our study, the Prospective Outcomes of Injury Study, aims to quantitatively identify predictors of disability following injury and to qualitatively explore experiences and perceptions of injury outcomes. Discussion. Responses to the Treaty included: consultation with Maori groups, translation of the questionnaire into te reo Maori, appointment of interviewers fluent in te reo Maori, sufficient numbers of Maori participants to allow Maori-specific analyses and the inclusion of a Maori-specific qualitative component. While this article is located within the New Zealand context, we believe it will resonate with, and be of relevance to, health researchers in other former settler societies. We do not contend this project represents an 'ideal' model for undertaking population-based research. Instead, we hope that by describing our efforts at responding to the Treaty, we can prompt wider debate of the complex realities of the research environment, one which is scientifically, ethically and culturally located. [ABSTRACT FROM AUTHOR]

‘Asian’ is increasingly used as an ethnic category in the health sector in New Zealand but does not have a ‘natural’, fixed, uncontested meaning. Two differing constructions of ‘Asian’ are commonly used in New Zealand. One is racially based and includes only East and Southeast Asian peoples. It is commonly employed in popular discourse and by the media. The other construction includes peoples from East, South and Southeast Asia, but excludes peoples from the Middle East and Central Asia. This construction is recent and unique to New Zealand and is being increasingly operationalised in the health sector. This use for planning and research is problematic. For the health sector, ‘Asian’ does not differentiate a group of people with shared characteristics in terms of health status or needs. The diversity of the ‘Asian’ category, with several axes of difference, will result in an averaging of health indicators. This may result in the high health needs of groups within this category being masked or the inappropriate targeting of services. Another major concern is the general lack of acknowledgement of the contestable nature of the ‘Asian’ category or justification for its use. However, the ‘Asian’ category provides a political platform to advocate for resources and enable research into the previously ignored health status of the diverse ‘Asian’ population. Despite its shortcomings, usage of the category is likely to continue in the New Zealand health sector. As such, the sector needs to be aware of the limitations of the category and show greater precision in its use. [ABSTRACT FROM AUTHOR]

Objective. Public social policies in New Zealand assume that there are fundamental differences between Maori views of health phenomena and non-Maori perceptions. The biomedical model and a Maori model known as Te Whare Tapa Wha are commonly employed to characterise these differences. Using the categorical ethnicity demarcation 'Maori/non-Maori' we investigate this claim with respect to mental health literacy about depression. Design. Participants were randomly selected from the General and Maori Electoral Rolls and recruited by post (N=205). A vignette methodology was employed and involved the development of a fictional character as a target stimulus who exhibited the minimum DSM-IV-R criteria for a major depressive disorder. Participants responded to items regarding problem recognition, well-being, causal attributions, treatment preferences, and likely prognosis. Results. The majority of Maori and non-Maori participants correctly identified the problem the vignette character was experiencing and nominated congruent attributions for the causes of the problem. In relation to treatment strategies and likely prognosis, independent of self-assigned ethnicity, participants rated professional treatments above alternative options. Overall the categorical ethnicity distinction 'Maori and non-Maori' produced no systematic variation with regards to individual evaluative responses about a major depressive disorder. Conclusions. Contrary to the embedded assumption within New Zealand's public health strategies that there are essential differences between the way Maori and non-Maori view health problems, and that the categorical ethnicity demarcation reliably reflects these differences, we found no evidence for the veracity of this claim using a major depressive disorder as a target for judgements. Alternative explanations are canvassed as to why this assumption about fundamental differences based on categorical ethnicity has gained ascendancy and prominence within the sphere of New Zealand health. [ABSTRACT FROM AUTHOR]

Explains the results of a study on relationships between body mass index (BMI) and cardiovascular risk factors in 279 Europeans and 231 Polynesian Pacific Islanders in New Zealand. Weaker association between BMI and cardiovascular risk factors for Pacific Islanders than for Europeans.